Free medial plantar perforator flaps for the resurfacing of finger and foot defects.

In this article, three cases in which free medial plantar perforator flaps were successfully transferred for coverage of soft-tissue defects in the fingers and foot are described. This perforator flap has no fascial component and is nourished only by perforators of the medial plantar vessel and a cutaneous vein or with a small segment of the medial plantar vessel. The advantages of this flap are minimal donor-site morbidity, minimal damage to both the posterior tibial and medial plantar systems, no need for deep dissection, the ability to thin the flap by primary removal of excess fatty tissue, the use of a large cutaneous vein as a venous drainage system, a good color and texture match for finger pulp repair, short time for flap elevation, possible application as a flow-through flap, and a concealed donor scar.

Free tensor fasciae latae perforator flap for the reconstruction of defects in the extremities.

In the three cases presented in this study, free tensor fasciae latae perforator flaps were used successfully for the coverage of defects in the extremities. This flap has no muscle component and is nourished by muscle perforators of the transverse branch of the lateral circumflex femoral system. The area of skin that can by nourished by these perforators is larger than 15 x 12 cm. The advantages of this flap include minimal donor-site morbidity, the preservation of motor function of the tensor fasciae latae muscle and fascia lata, the ability to thin the flap by removing excess fatty tissue, and a donor scar that can be concealed. In cases that involve transection of the perforator above the deep fascia, the operation can be completed in a very short period of time. This flap is especially suitable as a free flap for young women and children who have scars in the proximal region of the lateral thigh or groin region that were caused by split-thickness skin grafting or full-thickness skin grafting during previous operations.

One-stage facial augmentation with an intraoral groin adipose flap transfer.

A free groin adipose flap using an intraoral approach was used to correct facial contour deformities instead of a groin dermis-fat flap. The major disadvantages of the latter flap are that multistage debulking procedures are required and there are wide postoperative donor scars because of the wide skin portion included in the flap. To overcome these weaknesses the authors developed a free groin, customized ("berry picked") adipose flap, which was transferred by an intraoral approach for reconstruction of congenital hemifacial (orbitozygomatic) hypoplasia. The advantages of this method include one-stage augmentation without secondary defatting, no skin grafting of the donor defect, a donor scar in a concealed area, and possible transfer through an intraoral approach that results in minimal invasive surgery with no scar at the graft site.

Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities.

Over the last eight years, the authors analyzed obstructive lymphedema of a unilateral upper extremity in a total of 27 females, comparing the use of supramicrosurgical lymphaticovenule anastomoses and/or conservative treatment. The most common cause of edema was mastectomy, with or without subsequent radiation therapy for breast cancer. As an objective assessment of the extent of edema, the circumferences of the affected and opposite normal forearms were measured at 10 cm below the olecranon of the arm. Twelve of these patients received continual bandaging. In these patients, the average excess circumference of the affected arm was 6.4 cm over that of the normal forearm; the average duration of edema before treatment was 3.5 years; the average period for conservative treatment was 10.6 months; and the average decrease in circumference was 0.8 cm (11.7 percent of the preoperative excess). Twelve patients underwent surgery and postoperative continual bandaging. In these patients, the average excess circumference was 8.9 cm; the average duration of edema before surgery was 8.2 years; the average follow-up after surgery was 2.2 years; and the average decrease in circumference was 4.1 cm (47.3 percent of the preoperative excess). These results indicated that supermicrolymphaticovenular anastomoses with postoperative bandaging have a valuable place in the treatment of obstructive lymphedema.

Combined submental flap with toe web for reconstruction of the lip with oral commissure.

We present a new method employing a combined submental island flap and dorsalis pedis flap with the first toe web for reconstruction of a large lip defect including the oral commissure. The advantages of this method are: there is an excellent colour match; an anatomical structure similar to that of the oral commissure produces excellent results; there is superb function of the oral commissure; a donor-scar deformity can be avoided, since both flaps come from concealed areas; and good lining by the thin dorsal skin of the foot and submental skin results in a single-stage operation. The disadvantages are that complicated microvascular anastomoses may be required and there is a possibility of venous congestion of the submental flap in cases with a hypoplastic venous system. The use of the anterior jugular vein within the flap may be a key to overcoming this problem.

Deep inferior epigastric perforator dermal-fat or adiposal flap for correction of craniofacial contour deformities.

Craniofacial contour deformities are difficult to reconstruct. This article summarizes the authors' use of deep inferior epigastric perforator dermal-fat or adiposal flaps in eight patients with such deformities. Of these patients, three had traumatic craniofacial or facial deformities, one had congenital craniofacial deformity, two had hemifacial atrophy (one because of radiation), one had hemifacial microsomia, and one had localized frontonasal lipodystrophy. Stable restoration of the facial contour was achieved in all eight patients. The advantages of this flap are numerous. It has minimal donor-site morbidity, because the rectus abdominis muscle is preserved as a whole, and it accommodates pregnancy in female patients. Simultaneous elevation of this flap during preparation of the recipient site makes it possible to complete surgery in a shorter time than with the scapular flap. Furthermore, a considerable amount of the superficial or deep fatty layer can be removed primarily, making a bulky flap into a thinner one. This flap also allows the use of a large transverse abdominal ellipse of skin, fat, and Scarpa's fascia with abdominoplasty closure. Conversely, it requires a technically difficult dissection of the muscle perforator and skin grafting of donor defects in patients with a large dermal-fat flap. Also, additional minor operations may be necessary to reduce fat volume around the perforator. Ultimately, the deep inferior epigastric perforator adiposal flap seems to be suitable for craniofacial contouring surgery. It is especially indicated for use in children and female patients who are expecting to have children.

Fingertip reconstructions using partial-toe transfers.

Fifty-six partial toes were transferred to reconstruct fingertip deficits. The transfers from the big toe mainly consisted of 3 trimmed big toetips, 3 vascularized nail grafts, 3 onychocutaneous flaps, 19 thin osteo-onychocutaneous flaps, and 2 hemipulp flaps. The transfers from the second toe mainly consisted of 8 trimmed second toetips, 5 reduced second toes, and 9 whole distal phalanges. The average values of postoperative sensory recovery of the osteo-onychocutaneous flaps including the vascularized nail grafts were 3.1 (Semmes-Weinstein test) and 6.3 mm (moving two-point discrimination) at 2.6 years after the transfer; those of the thin osteo-onychocutaneous flaps were 3.1 and 7.2 mm at 2.0 years after surgery; those of the trimmed big toe tip transfers were 3.61 and 6.5 mm at 1.8 years after surgery; and those of the trimmed second toetip transfers were 3.37 and 6.3 mm at 2.6 years after transfer. Those of the distal phalanx of the second toe were 3.41 and 7.9 mm at 1.2 years after surgery, and those of the reduced second toe were 3.2 and 6.7 mm at 10.6 months after surgery.

Dynamic reconstruction of the abdominal wall using a reinnervated free rectus femoris muscle transfer.

Dynamic reconstruction of the abdominal wall using a free reinnervated rectus femoris muscle and an island tensor fascia lata transfer was performed for a large herniation with loss of the bilateral rectus abdominis muscles of the abdominal wall. The tensor fascia lata transfer was used to close an inner side of the abdominal defect, and the rectus femoris muscle replaced the rectus abdominis muscle deficit. The motor nerve of the rectus femoris muscle was sutured to the motor branch of the intercostal nerve. Postoperatively, the transferred rectus femoris muscle was reinnervated via electromyography, and there was no abdominal protrusion and no hernia recurrence.

Ear helix flap for reconstruction of total loss of the upper eyelid.

We present a patient with a recurrent carcinoma of the right upper eyelid who underwent resection of the subtotal upper eyelid resulting in a full-thickness defect. The eyelid was reconstructed with advanced conjunctival lining and an ascending helix chondrocutaneous flap from the right auricle. This flap was nourished with a reverse flow of the frontal branch of the superficial temporal vessels. A superficial temporal vein of the flap was anastomosed to the zygomaticofacial branch of the superficial temporal vein at the lateral canthal region to ensure adequate drainage. The flap survived without any congestion. An ascending helix flap is the best candidate for total loss of the upper eyelid.

Free combined anterolateral thigh flap and vascularized fibula for wide, through-and-through oromandibular defects.

Through-and-through oromandibular defects require the greatest amount of soft-tissue volume among the transfers for head and neck defects. A new method, a large anterolateral thigh flap combined with a vascularized fibula graft in a chimera fashion, has been used for two patients with wide through-and-through oromandibular defects. Among the candidates for such a large skin flap, the anterolateral thigh flap seems to be the best, for the following reasons. (1) Its pedicle, the lateral circumflex femoral system, has several major branches of equal size of anastomosis of the peroneal vessels. (2) As the majority of such patients with multiple previous surgery have lost recipient vessels near the mandible, the longest vascular pedicle is required. (3) There is no need for positional changes, and simultaneous flap elevation with the tumor resectioning is possible. (4) Use of the fibula allows for reconstruction of the entire mandible, if necessary. (5) Some of the shortcomings of individual donor sites for massive composite osteocutaneous flaps are minimized, because each component consists of two donor sites. (6) Operating time for this flap elevation is minimized, compared to that for massive composite osteocutaneous flaps, because the individual components can be obtained simultaneously by two teams.

Paraumbilical perforator flap without deep inferior epigastric vessels.

With the introduction of supramicrosurgery, a new paraumbilical perforator flap without a deep inferior epigastric vessel and with very small perforator anastomoses was used for nine patients. The abdominal defects of two patients, the lower leg or foot defects of five patients, and the scalp defects of two patients were repaired with an island perforator flap. The advantages of the paraumbilical perforator flap are as follows: (1) there is a very short operating time for flap elevation; (2) there is no invasion or sacrifice of any rectus abdominis muscle; (3) for middle-aged, obese patients, the donor site may be the best from the cosmetic point of view; (4) many small recipient vessels to anastomose the perforator exist throughout the body; (5) a thin skin flap with adequate thickness can be created easily with simultaneous removal of fatty tissue; (6) secondary defatting around the perforator can be done by minor surgery under local anesthesia; and (7) a vascularized adiposal flap with adequate thickness can be created easily. This flap seems to be indicated for female patients with defects in the abdominal wall and the lower leg. The island flap can easily resurface abdominal skin defects, such as intestinal fistula or radiation ulcers. The free flap is suitable for covering defects in the lower leg, foot, and scalp temporarily before administration of a tissue expander.